Dear provider:
I am writing to welcome you to refer adult patients who are specifically seeking help with their chronic insomnia. Helping such patients has become a very satisfying part of my practice. It is gratifying to see most of them get significantly better within a relatively short period of time.
The method I use is Cognitive Behavioral Therapy for Insomnia (CBT-I). The research shows that CBT-I is typically more effective than medications, produces more lasting results, and has fewer side effects. For this reason, clinical guidelines published by two major medical associations have recommended CBT-I as the preferred treatment for chronic insomnia for most people.1 In my experience, patients who make good faith efforts to implement CBT-I experience significant benefits and most of them typically no longer meet diagnostic criteria for insomnia.
Many of the factors that maintain chronic insomnia can be addressed with behavior change. Often, people just need to know what to do and how to do it. CBT-I guided by a therapist is often conducted in about 4-6 sessions over about 2-3 months. I can also assist patients who wish to discontinue sleep medication in consultation with their prescribing physician.
Below is a brief overview of CBT-I.
Thank you,
Nelson Binggeli, PhD
Licensed Psychologist
1American College of Physicians: Management of chronic insomnia disorder in adults: A clinical practice guideline (2016); American Academy of Sleep Medicine: Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults (2017)
A Brief Overview of CBT for Insomnia (CBT-I)
What is CBT-I?
CBT-I is a behavioral therapy that has been shown to be highly effective in treating chronic insomnia. It is typically more effective than medications, produces more lasting results, and has fewer side effects. For this reason, two major medical associations have recommended CBT-I as the preferred treatment for chronic insomnia for most people.1
Many of the factors that maintain chronic insomnia can be addressed with behavior change. Often, people just need to know what to do and how to do it. CBT-I guided by a therapist is often conducted in about 4-6 sessions over about 2-3 months. In my experience, patients who make good faith efforts to implement CBT-I experience significant benefits within a relatively short period of time. If they stick with it, most people typically no longer meet diagnostic criteria for an insomnia disorder.
CBT-I in practice
For patients, CBT-I often requires making significant behavior changes, overcoming fear of change, and perhaps learning a new skill (e.g., a relaxation or meditative technique). For this reason, it can be helpful to obtain the support and guidance of a therapist who knows how to guide people through the process. A therapist can help patients identify which behavior changes are the most important, customize a general approach to their unique situation and preferences, troubleshoot difficulties, and monitor their progress.
What maintains chronic insomnia and what can be done about it?
Everyone has their own unique story about what contributed to the development of their chronic insomnia. However, there are often three major factors that maintain most people’s insomnia. Each of them can be effectively addressed by specific behavioral strategies.
First, it is likely that the person’s biological rhythms that govern sleep have become disrupted (i.e., circadian rhythm and homeostatic sleep pressure). As a result, they are not sufficiently sleepy when they want to be sleepy. Behaviors that help to maintain biological sleep rhythms are maintaining a regular wake time 7 days a week and not going to bed too early (e.g., more than 8 hours before the regular wake time). When a person has been experiencing chronic insomnia, these behaviors alone may not be sufficient to restore sleep rhythms. Fortunately, there is a strategy that is highly effective. It involves temporarily reducing the amount of time the person spends in bed. This increases sleepiness during the sleep period, improves sleep quality, and helps to establish more regular sleep rhythms. This is followed by going to bed progressively earlier until they are getting enough sleep.
Second, it is likely that the person’s mind has come to associate their bed with being distressed about being awake. This can cause them to experience habitual responses while in bed that that interfere with sleep. Behaviors that strongly associate the bed with sleep are not engaging in wakeful activities in bed (e.g., reading, watching TV) and not remaining in bed for extended periods when unable to sleep. Guidelines that have been shown to be effective for treating insomnia are: (1) Don’t get into bed unless you are sleepy; and (2) If awake in bed for more than 15-20 minutes, stop trying to fall asleep. Instead, get out of bed and engage in a low-key activity and don’t get back into bed until you do feel sleepy.
Third, the person may be too keyed up during the sleep period. This can be the result of muscle tension, a habit of ruminating and worrying while in bed, emotional distress about not sleeping, and trying too hard to fall asleep. Things that people can do to let go of physical and emotional tension include the following: (1) Employing relaxation techniques to let go of tension before getting into bed; (2) Learning meditative skills to let go of thoughts; (3) Maintaining a calm attitude during periods of insomnia; and (4) Refraining from exerting any effort to fall asleep.
In summary, common goals of CBT-I are to restore a person’s biological sleep rhythms, strengthen their mind’s association of their bed with sleep, and help them let go of psychological and physical tension. Other things can contribute to insomnia and there are additional approaches in CBT-I that I have not fully described, but this should give some idea of what is involved.
1References
Two major medical associations have recommended CBT-I as the preferred treatment for chronic insomnia for most people: The American College of Physicians and the American Academy of Sleep Medicine.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 2, 125-133.
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13, 2, 307–349.
Recommended self-help book based on CBT-I
Carney, C. E., & Manber, R. (2013). Goodnight mind: Turn off your noisy thoughts and get a good night's sleep. New Harbinger.